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Reforming health care: national or provincial leadership?

Which level of government should take the lead in reforming Canada’s ailing health care system? This question is fundamental. Either Ottawa or the provinces must take the initiative, or it’s hard to imagine much progress being made.

Dr. Jeffrey Turnbull, president of the Canadian Medical Association, delivered a major speech today in Toronto in which he gives his answer: the federal government.

This is not, of course, a self-evident conclusion. It flows from the history of Ottawa setting the basic rules for universal care under the Canada Health Act, and enforcing those principles by threatening to reduce transfer payments to any province that doesn’t live up to them. The opposing perspective emphasizes the constitutional responsibility for health care that rests primarily with the provinces, which tends to lead to the notion that provincial governments should drive any reform.

Turnbull doesn’t make a public-policy case for federal leadership so much as invite us to conceive of the health care in terms of a corporate analogy. He imagines the system as a sprawling company—it would be the third largest in North America, he observes, after Walmart and Exxon Mobil—with each of the federal, provincial and territorial health departments functioning as an autonomous operating unit.

“Its 14 divisions each carry out the same function,” Turnbull says, “but with 14 different IT systems and purchasing departments, no clear system for sharing best practices, and no evaluation of outcomes, either separately or as a whole.”

Viewed this way, it’s natural for Turnbull to posit a head office for this inefficient corporation that should be demanding greater unity of purpose and less duplication. “We ask the federal government to demonstrate courage and leadership,” he says. The challenge is to “harness the national will to reshape [health care] for the future.”

But it’s not all that easy to make the leap from local problems to national solutions.

For instance, Turnbull is at his most compelling when he tells a story from Ottawa Hospital, where he practices. An 80-year-old woman went through all the taxing preparations necessary for surgery to fix an aneurism—only to have the operation cancelled because the hospital lacked a bed for her. “Sobbing,” Turnbull says, “she told me she just couldn’t go through the process again.”

A whole lot of Canadians have a sorry tale or two like that to tell. In the annecdote Turnbull relates, the solution would clearly be to invest in new long-term care facilities in and around Ottawa. He explains how his hospital is now stuck, at any given time, with 150 or so patients filling its acute care beds while they wait for space to open up elsewhere for appropriate long-term care.

Does fixing myriad problems of that sort cry out for a national strategy? Turnbull suggests another parallel, this time to a recent public-sector initiative—the Harper government’s heavily promoted Canadian Economic Action Plan. Launched in the 2009 budget, its aim was to inject stimulus into the badly slumping economy, largely through short-term infrastructure spending.

“A Health Care Action Plan, like its economic counterpart, would call on the participation of the provinces and the municipalities to leverage transformative change,” Turnbull says. “It would address not only health infrastructure needs, but transform the system to ensure more effective use of HR, to better incorporate health IT, and to introduce new accountability mechanisms.”

The type of leverage he refers to is not a complicated matter when it comes building, say, roads or arenas. That’s not transformational stuff: Ottawa typically puts up money for a project only if a province and municipality match those funds. The notion of using federal money in the same way as the incentive for a shared-cost reform of health care is an intriguing one.

When it comes to the economy, though, there’s not much debate about Ottawa’s right to take the lead. A federally directed revamp of health care—modeled on the 2009 economic action plan and inspired by a vision of the system as something like a coast-to-coast corporation that needs a more visionary head office—would be far more contentious.

For one thing, it would be difficult to reconcile this model with the Prime Minister’s “Open Federalism” philosophy, under which Ottawa is meant to defer to the provinces in their areas of jurisdiction. For another, Turnbull would have to show how a much more national system could be designed without building in the inefficiencies that often come with centralization.

These are not insurmountable hurdles. A creative federal government might find a way to inspire provincial buy-in for reform without coercing anyone to play along. Reforms might be national in scope without succumbing to rigid centralization.

Still, when you think about it, running a company or ramping up an infrastructure program look easy by comparison.

Or 14 separate laboratories replicating each other's activities, competing against each other for human resources, and duplicating each other's areas of expertise, all the while creating a patchwork of standards.

You are, I'm sure, familiar with the notion of economies of scale. Why would it not apply here?

Silly Cats! Of course there is. Let's say you are an Ontarian – and you get sick in Alberta. Will they treat you for free? Will they have the same proven and approved treatments there as back in Ontario?
What does make sense is – for standards to be set and agreed nationally – and service to be delivered locally! Ontario is doing a pretty good job here – with the 14 regional LHINs each responsible for determining what the demographic in their region needs – and then getting the private sector health care service providers – hospitals, doctors, labs etc. to bid to deliver them.

Cats has a somewhat Manichean view of the world which often proves itself at odds with the majority of rational thinking people on these boards. To your point, he (she?) did in fact propose a modest idea this morning. However, thanks to his past postings and reputation, few take him seriously. He has, frankly, lost the privilege of proposing interesting ideas.

My first thought was: that sounds like a reasonable idea. I'm not sure I support it, but there's at least weight to it and it could stand to be seriously considered.

My second thought was: even Cats might be right twice a day.

My third thought: if healthcare is to be completely devolved to the provinces, then how does one take the lab approach, when there is no longer any constitutional lever to apply the "winning experiment" nationally? Does anyone really believe the provinces will let go of their established fiefdoms and rearrange/dissolve their ministries and ministers after ten years or whatever of experimenting and spending and taking the heat for all their own decisions, just because their neighbor province was able to produce a marginally better result?

Which led to my fourth thought: when I was ten or twelve and discovering logic and how certain types of events were mathematically predictable, I thought "this means every problem in the world can be solved, if only people would wake up and use their brains!" Then I grew up and realized that plans are complicated by the messy inclusion of actual people, and that I wasn't the first pre-teen to have (and eventually lose) that Grand Plan for Fixing Everything.

Some ideas only look good as long as they stay on paper.

Halo_Override on March 1, 2011 at 3:40 pm

And if we ONLY have one national system how will we find better methods of doing things in the first place ?

Plenty of ways to take things national. The most obvious is national conferences for doctors. National meetings for ministers. Think tanks throwing out reports.

Ministers of health don't care about credit. They care about health care eating up 50+% of their provincial budget and leaving nothing for education.

Well the Cons' method for proceeding on a single national securities regulator could be an inspiration, were we led by a Pearson. Since there would seem to be economies of scale (rather large ones, I'd guess) from further coordinated action by these 14 providers, be it purchasing, administration and functioning (ex: you have space for more patients needing operation A, and I have space for those needing operation B, so let's trade), etc., then any such coordination, by even a few provinces, would provide such efficiencies for all, govts, employees and patients, that it would be difficult, it seems to me, for the others to resist the pull of the "national" body. Quite apart from the traditional "keeping up with the Jones'" federalist strategy of the past, the financial argument for govts would seem overwhelming, whether they'd like to or not, in a perfect world, given their provincialist druthers.

As the ball gets rolling, and the advantages become clear, the disadvantages for any provincialist absolutist holdouts, would conversely, deepen. It would not simply be clearly counterproductive to the best interests of their residents, financially and operationally, it would place them at a competitive disadvantage, as others' finances could invest their health care savings dividend in other programs/paying down debt/tax cuts. It would be almost impossible for anyone not to join. Only Alberta might be able to afford to cut off its nose to spite its face, but as that would be contrary to their interests, and their residents are not constitutionally ideological, only economically, it would be unlikely.

Quebec would want to hold out. The financial argument would be overwhelming though, especially given its particular political economy – it would indeed be the province to most profit from such a scheme, outside of nationalist consideratioins.

It is indeed the very kind of thing that a federation is supposed to do, providing the sort of benefits from collective action that political units could not achieve alone.

Well the Cons' method for proceeding on a single national securities regulator could be an inspiration, were we led by a Pearson. Since there would seem to be economies of scale (rather large ones, I'd guess) from further coordinated action by these 14 providers, be it purchasing, administration and functioning (ex: you have space for more patients needing operation A, and I have space for those needing operation B, so let's trade), etc., then any such coordination, by even a few provinces, would provide such efficiencies for all, govts, employees and patients, that it would be difficult, it seems to me, for the others to resist the pull of the "national" body. Quite apart from the traditional "keeping up with the Jones'" federalist strategy of the past, the financial argument for govts would seem overwhelming, whether they'd like to or not, in a perfect world, given their provincialist druthers.

As the ball gets rolling, and the advantages become clear, the disadvantages for any provincialist absolutist holdouts, would conversely, deepen. It would not simply be clearly counterproductive to the best interests of their residents, financially and operationally, it would place them at a competitive disadvantage, as others' finances could invest their health care savings dividend in other programs/paying down debt/tax cuts. It would be almost impossible for anyone not to join. Only Alberta might be able to afford to cut off its nose to spite its face, but as that would be contrary to their interests, and their residents are not constitutionally ideological, only economically, it would be unlikely.

Quebec would want to hold out. The financial argument would be overwhelming though, especially given its particular political economy – it would indeed be the province to most profit from such a scheme, outside of nationalist consideratioins.

It is indeed the very kind of thing that a federation is supposed to do, providing the sort of benefits from collective action that political units could not achieve alone.

It the direction of the Ontario government to decentralize health care decision making from Queen's Park to the Local Health Integration Networks. Thus, putting the case of the Ottawa woman whose surgery was cancelled at a macro policy level, the Champlain LHIN would decide what is the most appropriate solution to address the acute care hospital bed shortage in Ottawa (more hospitals bed, long-term care beds, home care etc). Of course there are a lot of criticisms about the performance of the LHINs – some justified and some just crass political manoeuvring by the Ontario PCs. That said, it is rare that you hear an argument for centralization at the provincial level let alone the federal level.

It is important to note that there is a lot of complexity and variation between provinces and within provinces in the healthcare sector because although it is mostly a government funded system, the health care corporations (hospitals, long-term care homes, family health teams, community laboratories) are independent entities unlike the various branches and operating arms of a corporation.

Are we a united or divided country? When I read some of these comments I wonder. In any sain system divisions are limited, shouldn't we have the same health system from one ocean to the other no matter what income one makes?

It the direction of the Ontario government to decentralize health care decision making from Queen's Park to the Local Health Integration Networks. Thus, putting the case of the Ottawa woman whose surgery was cancelled at a macro policy level, the Champlain LHIN would decide what is the most appropriate solution to address the acute care hospital bed shortage in Ottawa (more hospitals bed, long-term care beds, home care etc). Of course there are a lot of criticisms about the performance of the LHINs – some justified and some just crass political manoeuvring by the Ontario PCs. That said, it is rare that you hear an argument for centralization at the provincial level let alone the federal level.

It is important to note that there is a lot of complexity and variation between provinces and within provinces in the healthcare sector because although it is mostly a government funded system, the health care corporations (hospitals, long-term care homes, family health teams, community laboratories) are independent entities unlike the various branches and operating arms of a corporation.

Are we a united or divided country? When I read some of these comments I wonder. In any sain system divisions are limited, shouldn't we have the same health system from one ocean to the other no matter what income one makes?

Or 14 separate laboratories replicating each other's activities, competing against each other for human resources, and duplicating each other's areas of expertise, all the while creating a patchwork of standards.

You are, I'm sure, familiar with the notion of economies of scale. Why would it not apply here?

"For one thing, it would be difficult to reconcile this model with the Prime Minister's “Open Federalism” philosophy, under which Ottawa is meant to defer to the provinces in their areas of jurisdiction."

What Open Federalism philosophy? These are the guys who are nationalizing & federalizing securities regulation even though the provinces already have a passport system in operation to achieve the same thing.

"For one thing, it would be difficult to reconcile this model with the Prime Minister's “Open Federalism” philosophy, under which Ottawa is meant to defer to the provinces in their areas of jurisdiction."

What Open Federalism philosophy? These are the guys who are nationalizing & federalizing securities regulation even though the provinces already have a passport system in operation to achieve the same thing.

There have been no end of analysis and reports. But the movers and shakers are
going to keep trying until they get the answers they want. Only then will it all stop ..
because, well, … it's settled dontchaknow.

I wonder if anyone realizes that Canada is the only country in the world that makes it a crime for a citizen to buy healthcare outside the public system. Even European countries allow it.
In Canada, we have a coddled and very inefficient government system in every sector in which the government has it's hands. Canadians are finally waking up to this fact. Therefore, expect to see privately run hospitals that accept provincial healthcards and private and for-profit specialist clinics that perform things like joint replacements, gall bladder surgeries, etc. The country has no other choice in this matter but to accept private institutions to alleviate the strain on the system.

I wonder if anyone realizes that Canada is the only country in the world that makes it a crime for a citizen to buy healthcare outside the public system. Even European countries allow it.
In Canada, we have a coddled and very inefficient government system in every sector in which the government has it's hands. Canadians are finally waking up to this fact. Therefore, expect to see privately run hospitals that accept provincial healthcards and private and for-profit specialist clinics that perform things like joint replacements, gall bladder surgeries, etc. The country has no other choice in this matter but to accept private institutions to alleviate the strain on the system.

There have been no end of analysis and reports. But the movers and shakers are
going to keep trying until they get the answers they want. Only then will it all stop ..
because, well, … it's settled dontchaknow.

these sound like ideas worth debating, and as they run contrary to CPC policy, I wonder if the LPC is paying attention? (I doubt the NDP would be too sympathetic to a model that compares TC Douglas' sacred legacy to "a sprawling company—it would be the third largest in North America… after Walmart and Exxon Mobil")

these sound like ideas worth debating, and as they run contrary to CPC policy, I wonder if the LPC is paying attention? (I doubt the NDP would be too sympathetic to a model that compares TC Douglas' sacred legacy to "a sprawling company—it would be the third largest in North America… after Walmart and Exxon Mobil")

Silly Cats! Of course there is. Let's say you are an Ontarian – and you get sick in Alberta. Will they treat you for free? Will they have the same proven and approved treatments there as back in Ontario?
What does make sense is – for standards to be set and agreed nationally – and service to be delivered locally! Ontario is doing a pretty good job here – with the 14 regional LHINs each responsible for determining what the demographic in their region needs – and then getting the private sector health care service providers – hospitals, doctors, labs etc. to bid to deliver them.

Cats has a somewhat Manichean view of the world which often proves itself at odds with the majority of rational thinking people on these boards. To your point, he (she?) did in fact propose a modest idea this morning. However, thanks to his past postings and reputation, few take him seriously. He has, frankly, lost the privilege of proposing interesting ideas.

A huge part of the cost and hospital bed problem is the trend to institutionalizing the elderly, instead of providing support for them to remain in their homes. A great many of those now in seniors facilities could be at home with the effect of opening spaces for the immobile elderly to go into proper care facilities, out of the trauma beds. Deliver care (and xrays, etc) to the frail elderly, instead of institutionalizing them. Provincial jurisdiction; joint responsibility – it's a stone-dumb system that desperately needs good management and systemic overhaul.

A huge part of the cost and hospital bed problem is the trend to institutionalizing the elderly, instead of providing support for them to remain in their homes. A great many of those now in seniors facilities could be at home with the effect of opening spaces for the immobile elderly to go into proper care facilities, out of the trauma beds. Deliver care (and xrays, etc) to the frail elderly, instead of institutionalizing them. Provincial jurisdiction; joint responsibility – it's a stone-dumb system that desperately needs good management and systemic overhaul.

My first thought was: that sounds like a reasonable idea. I'm not sure I support it, but there's at least weight to it and it could stand to be seriously considered.

My second thought was: even Cats might be right twice a day.

My third thought: if healthcare is to be completely devolved to the provinces, then how does one take the lab approach, when there is no longer any constitutional lever to apply the "winning experiment" nationally? Does anyone really believe the provinces will let go of their established fiefdoms and rearrange/dissolve their ministries and ministers after ten years or whatever of experimenting and spending and taking the heat for all their own decisions, just because their neighbor province was able to produce a marginally better result?

Which led to my fourth thought: when I was ten or twelve and discovering logic and how certain types of events were mathematically predictable, I thought "this means every problem in the world can be solved, if only people would wake up and use their brains!" Then I grew up and realized that plans are complicated by the messy inclusion of actual people, and that I wasn't the first pre-teen to have (and eventually lose) that Grand Plan for Fixing Everything.

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